Cessation and reduction in smoking behavior: impact of creating a smoke-free home on smokers

Cessation and reduction in smoking behavior: impact of creating a smoke-free home on smokers Abstract The aim of this study was to assess the effect of a creating a smoke-free home (SFH) on cessation and reduction of cigarette smoking on low-income smokers. This secondary data analysis uses data from study participants who were originally recruited through 2-1-1 information and referral call centers in Atlanta (Georgia, 2013), North Carolina (2014) and the Texas Gulf Coast (2015) across three randomized controlled trials testing an intervention aimed at creating SFHs, pooling data from 941 smokers. Participants who reported adopting a SFH were more likely to report quitting smoking than those who did not adopt a SFH. This was true at 3-month follow-up and even more pronounced at 6-month follow-up and persisted when considering only those who consistently reported no smoking at 3 and 6 months. Among those who did not stop smoking, the number of cigarettes per day declined significantly more and quit attempts were more frequent for those who created a SFH compared with those who did not. Findings suggest that creating a SFH facilitates cessation, reduces cigarette consumption and increases quit attempts. Future studies should assess the long-term impact of SFHs on sustaining cessation. Introduction Associations between smoke-free homes (SFHs) and smoking behaviors have been well established in cross-sectional and observational longitudinal studies [1, 2]. However, no studies have investigated the impact of a household changing its rules to ban smoking in the home. A 2009 review by Mills et al. [1] showed fairly consistently that SFHs were associated with quit attempts, increased quit duration, and reduced relapse in both cross-sectional and longitudinal studies. In longitudinal studies those with a SFH were 50% more likely to quit smoking compared with those who allow smoking in the home. A more recent study [2] found that smokers who lived in homes with a smoking ban were 4.8 times more likely to quit smoking successfully than those living in homes without restrictions. Smokers living in a SFH also smoked fewer CPD (10.8 versus 16.5) [2]. Beyond cessation, Mills et al. [1] found a positive association between SFHs and reduction in smoking behavior in 13 out of 14 studies (both cross-sectional and longitudinal). Furthermore, studies a larger decrease in cigarettes smoked per day (CPD) in smokers living in SFHs over time [3–6]. Thus, previous observational research suggests that household smoking bans are related to (i) cessation and (ii) reduction in CPD. This study pools data from low-income participants of three randomized controlled trials (RCTs) to assess the impact of a newly created SFH on smokers. Materials and methods Participants Participants who allowed some smoking in their home were identified through 2-1-1 referral call centers in Atlanta (GA) [7], North Carolina [8] and Texas Gulf Coast [9] and recruited into an RCT testing a brief intervention—consisting of three mailings and a 20-min coaching call—aimed at creating a SFH. Further eligibility criteria were (i) having at least one smoker and one non-smoker in the household, (ii) speaking English and (iii) being at least 18-years old. Across trials, the intervention was successful in creating SFHs [7–9]. Notably, the intervention did not emphasize smoking cessation and only provided quit line contact information in one of the mailings and during the coaching call when relevant and requested. Many participants in the control groups also created a SFH, which we attribute to heightened consciousness of SFHs resulting from the studies’ repeated extensive assessments. This study pools data from the 941 smokers (62.5% of all participants) from intervention and control groups across the three RCTs who provided data on their SFH status and their smoking behaviors 3 and 6 months post-baseline. Measures SFH status was assessed through self-report at all three time-points (and validated through nicotine monitors at 3 months follow-up in the Atlanta trial) [7]. Smoking behaviors included smoking status, CPD and quit attempts in the past 3 months, and nicotine dependence [6, 10]. Demographic information on the participant’s ethnicity/race, age, gender, educational level, marital status, household income, household composition (including number of adult smokers and non-smokers in the household), and employment status were collected at baseline. Poverty level was calculated from household income and composition data using procedures from the Centers for Disease Control and Prevention, accounting for year of reporting and dichotomized into below/above federal poverty level. Data analysis After assessing univariate distributions and bivariate associations between outcomes and SFH ban status for all participants, logistic regression models were used to assess effects of creating a SFH on smoking status (cessation among baseline smokers) and smoking behaviors of those who continued to smoke. Regression analyses were first conducted with only the SFH ban status at follow-up as a predictor (unadjusted results) and then adjusted for the following covariates: group assignment (intervention or control group), trial site, age, gender, race (African American or not), household composition (being the only smoker in the house or not, living with a significant other, work status, having children under 18, under 5 and under 1 year of age in the household), and smoker characteristics (CPD at baseline, confidence to quit at baseline, and level of nicotine addiction). All analyses were conducted using SAS 9.4. Results Demographic characteristics, household composition, and smoking behaviors have been reported for each of the trials [7–9] and compared across trials. Overall, the smokers in this study were mostly female (85.0%), African American (73.2%), and living below the federal poverty level (80.9%). A large majority reported daily smoking (85.9%), and the mean number of CPD was 12.9 (SD = 8.70). At baseline, 56.5% had a partial smoking ban in the home, with the remainder having no rules or restrictions regarding smoking in the home. Table I shows that at 3-month follow-up, more participants who reported a smoking ban had stopped smoking [15.6 versus 4.5%, aOR = 3.90, 95% CI = (2.074, 7.329), P < 0.0001]. At 6-month follow-up, the difference was more pronounced, with 26.1% of those with a household smoking ban reporting they had ceased smoking compared with 5.1% of those who did not create a SFH [aOR = 6.56, 95% CI = (4.123, 10.422), P < 0.0001]. When considering only those who consistently reported no smoking at 3 and 6 months, 9.6% (compared with 1.9%) of those who had a SFH had stopped smoking [aOR = 5.43, 95% CI = (2.547, 11.562), P < 0.0001]. Table I. Impact of change in SFH ban status on smoking status and smoking behaviors in continued smokers from pooled trial data: Atlanta 2013, North Carolina 2014 and Texas Gulf Region 2015 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Table I. Impact of change in SFH ban status on smoking status and smoking behaviors in continued smokers from pooled trial data: Atlanta 2013, North Carolina 2014 and Texas Gulf Region 2015 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Among participants who did not stop smoking, the number of CPD was significantly reduced among those who had created a SFH at 3 months (M = −4.2, SD = 7.52 versus M = −1.5, SD = 6.59 P < 0.0001) and 6 months (M = −4.9, SD = 7.71 versus M = −2.5, SD = 6.59, P < 0.0001) compared with baseline. Furthermore, creating a SFH was related to an increased number of quit attempts and ‘activated’ some smokers who had indicated no quit attempts at baseline to attempt quitting. Discussion Findings from this study advance the growing body of evidence linking SFHs to cessation by providing the first data from prospective longitudinal studies of SFH adoption. Although observational research has suggested a link between household smoking bans and cessation and smoking behaviors [2–4, 6], this study allows us to draw stronger conclusions. Our data show that smokers who create a SFH are more likely to quit smoking. This is in line with research that has consistently shown that smoke-free environments lead to reduction in smoking prevalence, e.g. in workplaces [11]. Furthermore, our results also indicate a reduction in smoking for those with a SFH who continue to smoke. Similar effects have been reported after implementing other smoke-free policies and so it is not surprising that reducing the spaces in which smoking is allowed reduces cigarette consumption. This study has multiple strengths including the rigor of the studies, replication of results across three contexts, and its statistical power due to pooled data. Limitations are the self-report of smoking behaviors and the home-smoking ban. However, the self-report of home-smoking bans was validated using a bogus pipeline and nicotine monitors [7]. Public health implications Our findings provide yet another reason for tobacco control efforts to emphasize SFHs. It is possible that SFH interventions are viewed by smokers as less threatening than cessation interventions, yet with collateral benefits on cessation that accomplish the same goal. For example, some smokers receiving an overtly cessation-focused intervention might marshal their cognitive resources against messages that are clearly intended to get them to quit smoking. In contrast, SFH interventions might not evoke the same defensive reaction or counter-arguing [12]. Rather, they could help create conditions that make cessation easier or lead smokers who were not about to quit to consider it. Funding This work was supported by the National Cancer Institute’s State and Community Tobacco Control Research Initiative (grant number U01CA154282). The trials are registered with ClinicalTrials.gov number: NCT01625468. Conflict of interest statement None declared. References 1 Mills AL , Messer K , Gilpin EA , Pierce JP. The effect of smoke-free homes on adult smoking behavior: a review . Nicotine Tob Res 2009 ; 11 : 1131 – 41 . Google Scholar CrossRef Search ADS PubMed 2 Vijayaraghavan M , Messer K , White MM , Pierce JP. The effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States . Am J Public Health 2013 ; 103 : 2276 – 83 . Google Scholar CrossRef Search ADS PubMed 3 Gilpin EA , White MM , Farkas AJ , Pierce JP. Home smoking restrictions: which smokers have them and how they are associated with smoking behavior . Nicotine Tob Res 1999 ; 1 : 153 – 62 . Google Scholar CrossRef Search ADS PubMed 4 Borland R , Yong H-H , Cummings KM et al. Determinants and consequences of smoke-free homes: findings from the International Tobacco Control (ITC) Four Country Survey . Tob Control 2006 ; 15 : iii42 – 50 . Google Scholar CrossRef Search ADS PubMed 5 Shields M. Smoking bans: influence on smoking prevalence . Health Rep 2007 ; 18 : 9 . Google Scholar PubMed 6 Messer K , Mills AL , White MM , Pierce JP. The effect of smoke-free homes on smoking behavior in the U.S . Am J Prevent Med 2008 ; 35 : 210 – 16 . Google Scholar CrossRef Search ADS 7 Kegler MC , Bundy L , Haardorfer R et al. A minimal intervention to promote smoke-free homes among 2-1-1 callers: a randomized controlled trial . Am J Public Health 2015 ; 105 : 530 – 7 . Google Scholar CrossRef Search ADS PubMed 8 Williams RS , Stollings JH , Bundy ŁT et al. A minimal intervention to promote smoke-free homes among 2-1-1 Callers: North Carolina Randomized Effectiveness Trial . PLoS One 2016 ; 11 : e0165086 . Google Scholar CrossRef Search ADS PubMed 9 Mullen PD , Savas LS , Bundy ŁT et al. Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial . Tob Control 2016 ; 25 : i10 – 18 . Google Scholar CrossRef Search ADS PubMed 10 Biener L , Abrams DB. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation . Health Psychol 1991 ; 10 : 360 – 5 . Google Scholar CrossRef Search ADS PubMed 11 Hopkins DP , Razi S , Leeks KD et al. Smokefree policies to reduce tobacco use. A systematic review . Am J Prevent Med 2010 ; 38 : S275 – 89 . Google Scholar CrossRef Search ADS 12 Kreuter MW , Green MC , Cappella JN et al. Narrative communication in cancer prevention and control: a framework to guide research and application . Ann Behav Med 2007 ; 33 : 221 – 35 Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Education Research Oxford University Press

Cessation and reduction in smoking behavior: impact of creating a smoke-free home on smokers

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Abstract

Abstract The aim of this study was to assess the effect of a creating a smoke-free home (SFH) on cessation and reduction of cigarette smoking on low-income smokers. This secondary data analysis uses data from study participants who were originally recruited through 2-1-1 information and referral call centers in Atlanta (Georgia, 2013), North Carolina (2014) and the Texas Gulf Coast (2015) across three randomized controlled trials testing an intervention aimed at creating SFHs, pooling data from 941 smokers. Participants who reported adopting a SFH were more likely to report quitting smoking than those who did not adopt a SFH. This was true at 3-month follow-up and even more pronounced at 6-month follow-up and persisted when considering only those who consistently reported no smoking at 3 and 6 months. Among those who did not stop smoking, the number of cigarettes per day declined significantly more and quit attempts were more frequent for those who created a SFH compared with those who did not. Findings suggest that creating a SFH facilitates cessation, reduces cigarette consumption and increases quit attempts. Future studies should assess the long-term impact of SFHs on sustaining cessation. Introduction Associations between smoke-free homes (SFHs) and smoking behaviors have been well established in cross-sectional and observational longitudinal studies [1, 2]. However, no studies have investigated the impact of a household changing its rules to ban smoking in the home. A 2009 review by Mills et al. [1] showed fairly consistently that SFHs were associated with quit attempts, increased quit duration, and reduced relapse in both cross-sectional and longitudinal studies. In longitudinal studies those with a SFH were 50% more likely to quit smoking compared with those who allow smoking in the home. A more recent study [2] found that smokers who lived in homes with a smoking ban were 4.8 times more likely to quit smoking successfully than those living in homes without restrictions. Smokers living in a SFH also smoked fewer CPD (10.8 versus 16.5) [2]. Beyond cessation, Mills et al. [1] found a positive association between SFHs and reduction in smoking behavior in 13 out of 14 studies (both cross-sectional and longitudinal). Furthermore, studies a larger decrease in cigarettes smoked per day (CPD) in smokers living in SFHs over time [3–6]. Thus, previous observational research suggests that household smoking bans are related to (i) cessation and (ii) reduction in CPD. This study pools data from low-income participants of three randomized controlled trials (RCTs) to assess the impact of a newly created SFH on smokers. Materials and methods Participants Participants who allowed some smoking in their home were identified through 2-1-1 referral call centers in Atlanta (GA) [7], North Carolina [8] and Texas Gulf Coast [9] and recruited into an RCT testing a brief intervention—consisting of three mailings and a 20-min coaching call—aimed at creating a SFH. Further eligibility criteria were (i) having at least one smoker and one non-smoker in the household, (ii) speaking English and (iii) being at least 18-years old. Across trials, the intervention was successful in creating SFHs [7–9]. Notably, the intervention did not emphasize smoking cessation and only provided quit line contact information in one of the mailings and during the coaching call when relevant and requested. Many participants in the control groups also created a SFH, which we attribute to heightened consciousness of SFHs resulting from the studies’ repeated extensive assessments. This study pools data from the 941 smokers (62.5% of all participants) from intervention and control groups across the three RCTs who provided data on their SFH status and their smoking behaviors 3 and 6 months post-baseline. Measures SFH status was assessed through self-report at all three time-points (and validated through nicotine monitors at 3 months follow-up in the Atlanta trial) [7]. Smoking behaviors included smoking status, CPD and quit attempts in the past 3 months, and nicotine dependence [6, 10]. Demographic information on the participant’s ethnicity/race, age, gender, educational level, marital status, household income, household composition (including number of adult smokers and non-smokers in the household), and employment status were collected at baseline. Poverty level was calculated from household income and composition data using procedures from the Centers for Disease Control and Prevention, accounting for year of reporting and dichotomized into below/above federal poverty level. Data analysis After assessing univariate distributions and bivariate associations between outcomes and SFH ban status for all participants, logistic regression models were used to assess effects of creating a SFH on smoking status (cessation among baseline smokers) and smoking behaviors of those who continued to smoke. Regression analyses were first conducted with only the SFH ban status at follow-up as a predictor (unadjusted results) and then adjusted for the following covariates: group assignment (intervention or control group), trial site, age, gender, race (African American or not), household composition (being the only smoker in the house or not, living with a significant other, work status, having children under 18, under 5 and under 1 year of age in the household), and smoker characteristics (CPD at baseline, confidence to quit at baseline, and level of nicotine addiction). All analyses were conducted using SAS 9.4. Results Demographic characteristics, household composition, and smoking behaviors have been reported for each of the trials [7–9] and compared across trials. Overall, the smokers in this study were mostly female (85.0%), African American (73.2%), and living below the federal poverty level (80.9%). A large majority reported daily smoking (85.9%), and the mean number of CPD was 12.9 (SD = 8.70). At baseline, 56.5% had a partial smoking ban in the home, with the remainder having no rules or restrictions regarding smoking in the home. Table I shows that at 3-month follow-up, more participants who reported a smoking ban had stopped smoking [15.6 versus 4.5%, aOR = 3.90, 95% CI = (2.074, 7.329), P < 0.0001]. At 6-month follow-up, the difference was more pronounced, with 26.1% of those with a household smoking ban reporting they had ceased smoking compared with 5.1% of those who did not create a SFH [aOR = 6.56, 95% CI = (4.123, 10.422), P < 0.0001]. When considering only those who consistently reported no smoking at 3 and 6 months, 9.6% (compared with 1.9%) of those who had a SFH had stopped smoking [aOR = 5.43, 95% CI = (2.547, 11.562), P < 0.0001]. Table I. Impact of change in SFH ban status on smoking status and smoking behaviors in continued smokers from pooled trial data: Atlanta 2013, North Carolina 2014 and Texas Gulf Region 2015 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Table I. Impact of change in SFH ban status on smoking status and smoking behaviors in continued smokers from pooled trial data: Atlanta 2013, North Carolina 2014 and Texas Gulf Region 2015 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Three-month follow-up Six-month follow-up Full ban No full ban Full ban No full ban Cessation Smoking status n % n % P-value n % n % P-value     Former smokers 36 15.58 30 4.48 80 26.14 27 5.12     Continued smokers 195 84.42 639 95.52 <0.0001 226 73.86 500 94.88 <0.0001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.9 2.074 7.329 <.0001 6.02 3.47 10.47 <0.0001 Smoking behaviors in continued smokers Cigarettes per day Mean SD Mean SD P-value Mean SD Mean SD P-value     Number of cigarettes per day 7.9 6.91 11.7 8 <0.0001 7.3 6.06 11.1 7.94 <0.0001     Change in number of cigs per day −4.2 7.52 −1.5 6.59 <0.0001 −4.9 7.71 −2.5 6.59 <0.0001 Mean SE adjusted Mean SE         Multivariable regression −2.0 0.61 0.001 −2.5 0.63 <0.0001 Quit attempts (past 3 months) ‘All continued smokers’ n % n % n % n %     Any quit attempt (Yes reported) 50 56.18 189 42.57 0.02 75 61.98 163 44.54 0.001 aOR 95% CI aOR 95% CI         Multivariable logistic regression 2.86 1.457 5.626 0.002 2.33 1.269; 4.266 0.006 ‘Smokers without quit attempts at baseline’ n % n % n % n %     Any quit attempt (Yes reported)—‘activation’ 20 40 52 22.22 0.009 30 48.39 55 26.96 0.002 aOR 95% CI aOR 95% CI         Multivariable logistic regression 3.09 1.394; 6.848 0.006 3.00 1.426 6.322 0.004 Among participants who did not stop smoking, the number of CPD was significantly reduced among those who had created a SFH at 3 months (M = −4.2, SD = 7.52 versus M = −1.5, SD = 6.59 P < 0.0001) and 6 months (M = −4.9, SD = 7.71 versus M = −2.5, SD = 6.59, P < 0.0001) compared with baseline. Furthermore, creating a SFH was related to an increased number of quit attempts and ‘activated’ some smokers who had indicated no quit attempts at baseline to attempt quitting. Discussion Findings from this study advance the growing body of evidence linking SFHs to cessation by providing the first data from prospective longitudinal studies of SFH adoption. Although observational research has suggested a link between household smoking bans and cessation and smoking behaviors [2–4, 6], this study allows us to draw stronger conclusions. Our data show that smokers who create a SFH are more likely to quit smoking. This is in line with research that has consistently shown that smoke-free environments lead to reduction in smoking prevalence, e.g. in workplaces [11]. Furthermore, our results also indicate a reduction in smoking for those with a SFH who continue to smoke. Similar effects have been reported after implementing other smoke-free policies and so it is not surprising that reducing the spaces in which smoking is allowed reduces cigarette consumption. This study has multiple strengths including the rigor of the studies, replication of results across three contexts, and its statistical power due to pooled data. Limitations are the self-report of smoking behaviors and the home-smoking ban. However, the self-report of home-smoking bans was validated using a bogus pipeline and nicotine monitors [7]. Public health implications Our findings provide yet another reason for tobacco control efforts to emphasize SFHs. It is possible that SFH interventions are viewed by smokers as less threatening than cessation interventions, yet with collateral benefits on cessation that accomplish the same goal. For example, some smokers receiving an overtly cessation-focused intervention might marshal their cognitive resources against messages that are clearly intended to get them to quit smoking. In contrast, SFH interventions might not evoke the same defensive reaction or counter-arguing [12]. Rather, they could help create conditions that make cessation easier or lead smokers who were not about to quit to consider it. Funding This work was supported by the National Cancer Institute’s State and Community Tobacco Control Research Initiative (grant number U01CA154282). The trials are registered with ClinicalTrials.gov number: NCT01625468. Conflict of interest statement None declared. References 1 Mills AL , Messer K , Gilpin EA , Pierce JP. The effect of smoke-free homes on adult smoking behavior: a review . Nicotine Tob Res 2009 ; 11 : 1131 – 41 . Google Scholar CrossRef Search ADS PubMed 2 Vijayaraghavan M , Messer K , White MM , Pierce JP. The effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States . Am J Public Health 2013 ; 103 : 2276 – 83 . Google Scholar CrossRef Search ADS PubMed 3 Gilpin EA , White MM , Farkas AJ , Pierce JP. Home smoking restrictions: which smokers have them and how they are associated with smoking behavior . Nicotine Tob Res 1999 ; 1 : 153 – 62 . Google Scholar CrossRef Search ADS PubMed 4 Borland R , Yong H-H , Cummings KM et al. Determinants and consequences of smoke-free homes: findings from the International Tobacco Control (ITC) Four Country Survey . Tob Control 2006 ; 15 : iii42 – 50 . Google Scholar CrossRef Search ADS PubMed 5 Shields M. Smoking bans: influence on smoking prevalence . Health Rep 2007 ; 18 : 9 . Google Scholar PubMed 6 Messer K , Mills AL , White MM , Pierce JP. The effect of smoke-free homes on smoking behavior in the U.S . Am J Prevent Med 2008 ; 35 : 210 – 16 . Google Scholar CrossRef Search ADS 7 Kegler MC , Bundy L , Haardorfer R et al. A minimal intervention to promote smoke-free homes among 2-1-1 callers: a randomized controlled trial . Am J Public Health 2015 ; 105 : 530 – 7 . Google Scholar CrossRef Search ADS PubMed 8 Williams RS , Stollings JH , Bundy ŁT et al. A minimal intervention to promote smoke-free homes among 2-1-1 Callers: North Carolina Randomized Effectiveness Trial . PLoS One 2016 ; 11 : e0165086 . Google Scholar CrossRef Search ADS PubMed 9 Mullen PD , Savas LS , Bundy ŁT et al. Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial . Tob Control 2016 ; 25 : i10 – 18 . Google Scholar CrossRef Search ADS PubMed 10 Biener L , Abrams DB. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation . Health Psychol 1991 ; 10 : 360 – 5 . Google Scholar CrossRef Search ADS PubMed 11 Hopkins DP , Razi S , Leeks KD et al. Smokefree policies to reduce tobacco use. A systematic review . Am J Prevent Med 2010 ; 38 : S275 – 89 . Google Scholar CrossRef Search ADS 12 Kreuter MW , Green MC , Cappella JN et al. Narrative communication in cancer prevention and control: a framework to guide research and application . Ann Behav Med 2007 ; 33 : 221 – 35 Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Health Education ResearchOxford University Press

Published: May 16, 2018

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